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|Year : 2015 | Volume
| Issue : 2 | Page : 282-283
Chronic calcified extradural and subdural hematoma following a ventriculoperitoneal shunt placement
BO Djoubairou, Miloudi Gazzaz, Ibrahim Dao, Brahim El Mostarchid
Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V University, School of Medicine, Hay Riyad, Rabat, Morocco
|Date of Web Publication||5-May-2015|
Dr. B O Djoubairou
Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V University, School of Medicine, Hay Riyad, 1018 Rabat
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Djoubairou B O, Gazzaz M, Dao I, Mostarchid BE. Chronic calcified extradural and subdural hematoma following a ventriculoperitoneal shunt placement. Neurol India 2015;63:282-3
|How to cite this URL:|
Djoubairou B O, Gazzaz M, Dao I, Mostarchid BE. Chronic calcified extradural and subdural hematoma following a ventriculoperitoneal shunt placement. Neurol India [serial online] 2015 [cited 2019 Oct 21];63:282-3. Available from: http://www.neurologyindia.com/text.asp?2015/63/2/282/156316
A 22-year-old man was admitted with headache and vomiting but without any visual loss. His past history revealed placement of a medium pressure ventriculoperitoneal shunt (VP) at another hospital for the management of congenital hydrocephalus. He was not on regular follow up at that hospital but continued to be well despite the presence of a persisting learning difficulty since childhood. At admission, there was no past history of head injury. He was conscious and showed a mild mental retardation. There was neither loss of visual acuity nor the presence of papilledema. A cranial X-ray showed a parieto-occipital chronic calcified hematoma with presence of a ventriculoperitoneal shunt [Figure 1]a. His cerebral computed tomography (CT) showed a coexisting right parieto-occipital, chronic calcified extradural hematoma (CEDH) and a chronic calcified subdural hematoma (CSDH) associated with congenital hydrocephalus [Figure 1]b. His magnetic resonance imaging [Figure 1]c confirmed the associated subdural and extradural hematoma. Due to the absence of progressive neurological deficits and of intracranial hypertension, he was placed on analgesics that provided symptomatic relief in his symptoms within 5 days. He has been on a regular follow-up. At a follow-up of 3 months, he showed neither any recurrence of his previous symptoms nor of neurological deterioration.
|Figure 1: (a) Cranial X-ray showing the parieto-occipital chronic calcified hematoma and the presence of ventriculoperitoneal shunt; (b) Coronal CT scan parenchymal window confirming the right sided parieto-occipital chronic calcified extradural and subdural hematoma associated with congenital hydrocephalus; and, (c) Axial T1 MRI showed right-sided parieto-occipital chronic calcified extradural and subdural hematoma without any signs of an active hydrocephalus|
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A CSDH caused by over-drainage of the cerebrospinal fluid (CSF) consequent to a CSF diversion procedure is a well known entity and occurs in approximately 0.3-2.7% cases.  The incidence of CEDH is between 3.9 and 30%. It occurs more commonly in the younger age group due to the presence of lax adhesions between the dura and the calvarium.  To the best of the authors' knowledge, the simultaneous association of a CEDH and CSDH in a patient has not been reported till date. The pathogenic mechanisms responsible for the occurrence of calcification remain unclear. The currently proposed mechanisms include the presence of a poor circulation leading to lack of absorption of the hematoma in the subdural and extradural spaces associated with intravascular thrombosis. The insufficient arterial supply as well as inadequate venous return led to the presence of stagnant blood that subsequently underwent calcification. , Rapid ossification of a post-traumatic extradural hematoma in a child could be due to the occurrence of disproportionate repair of tissues following an acute injury. It has been postulated that damage to highly vascular tissues such as bone and dura initiates a tissue response that includes inflammation, repair, and remodeling. This natural sequence of the healing process is more rapid in children than in adults.  The occurrence of calcification in the case of a CSDH may be due to the presence of microscopic calcium deposits within the membranes of the hematoma that may proceed to extensive calcification and even ossification. An underlying metabolic abnormality that promotes calcification is another contributory factor.  The treatment remains a subject of controversy. Patients who are asymptomatic, elderly, or without progressive neurological deterioration may be managed conservatively. , The steps to prevent this complication include minimal CSF drainage at the time of placement of the ventricular catheter, a meticulous surgical technique, performance of a check CT scan after surgery (to ensure the absence of a postoperative hematoma), a gradual return of the patient to an upright position during postoperative nursing, and maintenance of a close watch on them following their successful discharge.
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